From theory to practice: conceptualising the guiding principles within the Regional Integration Fund (summary)

This report addresses the first of the central questions in our study (‘To what extent have meaningful and evaluable principles been articulated as part of RIF?’) and in answering the question provides a synthesis of the findings from evaluation data collected over the course of Year 1 of the RIF evaluation. This report is an overview of four reports produced by the team which is providing supporting evidence for our conclusions. This report draws together and synthesises findings from those.

Framework for Change (Verity and Llewellyn, 2023) which sets out an overview of the values, ideas and aspirations for change set out in the RIF, including the programme design and the wider context within which it is being implemented.

Rapid Realist Review of the literature (Tetlow et al., 2024) which describes the components of successful integrated care programmes and the barriers to their success.

Group Concept Mapping report (Wallace and Wallace, 2024) which explores areas of consensus and agreement around the underlying principles and concepts associated with the RIF.

In-depth Scoping Interviews report (Bryer and Bebb, 2024) which provides insights from stakeholders on the underlying ideas, concepts and design principles that have informed the development of RIF to date.

These four supporting evidence papers offer a window into the ideas and values informing the RIF from a range of angles and perspectives. From analysis of the total data collected, the study team has identified five cross cutting themes.

1. Conceptualisation of the principles or guiding directions underpinning ‘RIF’.
2. Aspirations for Change.
3. Complexities of realising the expected change in practice.
4. Development of the Models of Care.
5. Quality of data collection and reporting.

Broadly speaking there is support for the integrative and collaborative vision and ambition of RIF, for enacting the key principles of RIF, and there are signs of positive developments and progress towards the RIF goals. For instance, RIF funded work is building on pre-existing integration projects and this has supported these projects to ‘…hit the ground running immediately’ (Bryer and Bebb, 2024, p.20).

The architecture of RIF has incorporated lessons from previous Welsh Government funding schemes, such the Integrated Care Fund (ICF) and Transformation Fund (TF), which reinforced the importance of dedicated funds in supporting integration and the value of sharing good practice and evaluation insights. RIF has explicit principles to guide action, anchored in Welsh Government legislation and policies. There is also a clear focus on population groups and enablers.

As seen in the scoping interviews, there is a positive response to the intention and ambition of RIF. This assessment also is evident in the Group Concept mapping process with relatively positive ratings being assigned to the ‘strategic’ concepts underpinning RIF (‘Ambition to Change’, ‘Communication, Relationships and Networking’, and ‘Integration and Collaboration’) (Wallace and Wallace, 2024).

The Welsh Government investment period of for 5 years for the RIF scheme is viewed favourably by some Scoping interview respondents, reflecting a theme in the Rapid Realist Review that a precondition for effective integration is investment over time. Nonetheless, the pressures on core service budgets and ‘funding and demand management’, as identified in both the Group Concept mapping exercise and the Scoping Interviews, is creating a challenging fiscal environment with potential to undermine some of the RIF intentions.

Scoping interview respondents note that the various Communities of Practice associated with the iterative development of the Models of Care, are beginning to use the insight and intelligence from practice as they move to being more evidence based in their work. Mentioned in this respect were the Community Based Care Community of Practice, Hospital to Home, and the Supporting Families / NEST CoP.

Pertinently, evidence from the Rapid Realist Review suggested that generalising successful local and regional integrated care models to a national level, as is the intention with RIF, could be one way of successfully implementing programmes, alongside the importance of standardising integrated care policy and innovation on national levels. However, some Scoping interview respondents noted ambiguity about the meaning, purpose and intentions of the Models of Care, and disquiet about a potential misalignment with the Regional Partnership Boards focus on population groups (Bryer and Bebb, 2024).

Despite the support for the vision of the RIF and the Welsh Government policy aspirations it is pursuing, the realities of implementation or its application, are being seen and experienced as more problematic. RIF operates in a fast-changing policy context. The implications of these developments are raised by qualitative interviewees as possibly ‘pulling against integration’ (Bryer and Bebb, 2024, p.7).  Respondents discussed complexities in how the RIF is working in practice which relate to questions of clarity about key aspects of the RIF such as the Models of Care, scope for local responsiveness, issues around data collection and reporting, and the management and implications of RIF’s funding design complexity. The themes and issues emerging from the findings are summarised below.

Rapid Realist Review issues

• Autonomy and sustainability
• Co-location, collaboration, communication
• Common vision
• Barriers to integrated care
• Quality of evidence and data
• National, regional and local integrated care policy
• System integration and integrated care frameworks

GCM clusters

• Governance
• Communication, relationships, and networking
• Integration and collaboration
• Ambition to change
• Impact, outcomes, and evaluation
• Funding and demand management
• Complexity and constraints

Scoping interview themes

• Positive ambition, but tempered
• Ambiguity in design, especially in role and purpose of Models of Care
• Complexity, especially in evolving policy context
• Difficultly in being able to assess the difference made
• Challenging fiscal environment undermining design principles
• Alignment with regional priorities, or not
• Learning is shared, but sub-optimally

Therefore, the evidence collected to date raises questions about the best balance between prescribed RIF expectations and the capacity for regional and local autonomy and flexibility to plan and deliver integrated care in a changing environment.

Embedded narratives: concepts in tension within RIF

From this evidence, a complex picture emerges of the ways in which the principles associated with the integration of health and social care, and specifically with regard to the RIF, are conceptualised. Given the range and scope of principles currently being discussed and utilised in Welsh Government legislation, policies and practice, there are therefore perhaps opportunities, as evidenced by our work to date, for reconsideration of the underlying assumptions, ideas, and concepts of RIF.

Our synthesis of the data identified six ‘pairs’ of ideas, or concepts that were in some way competing with, or in tension with each other. These ‘conceptual dyads’ are to be found embedded in the narratives around RIF, drawn from the experiences described in the four key sources of evidence. The ‘dyads’ are our way of ‘sense-making’ the complexity of RIF. It is our way of understanding the interplay between the principles, values, concepts and constructs within RIF, with a view to evaluating these as the study moves forward.

These concepts are on a continuum and are in tension with each other. Below we provide a series of descriptions of these concepts as we understand them in the context of RIF. These are neither formal definitions – to provide such a thing would be to over-simplify an inherently complex situation – nor are they ‘fixed’, as they will change as the context changes.

Alignment | Aspiration

This dyad speaks to the nature of a Fund whose very purpose is to be aligned with and facilitate the implementation of policy objectives, but which has far loftier ambitions than just that given its stated intent to deliver on the promise of seamless services. These concepts often work against one another in the way people describe needing to deliver on the focused aims of the Fund, whilst being part of a whole-system, whole-sector transformation.

Control | Collaboration

This pair of ideas is most closely connected to the power dynamics inherent within RIF, and the extent to which sharing power (through co-design, co-production and collaboration) fluxes over time. This is not to imply that this dyad only operates between national and regional partners, but it is to recognise that it also operates within and between regions and the organisations they work with.

Fidelity | Flexibility

Our evaluation data highlights tensions around the issues of fidelity with the RIF guidance and the design principles (especially Models of Care), and the desire of those who are seeking to implement the Fund in practice to have additional levels of flexibility than currently offered, whether in respect of data collection, reporting requirements or other arrangements.

Accountability | Autonomy

Similar to the previous dyad, our data suggests there are tensions over the right balance between a proportionate approach to accountability, governance, and the spending of public money, alongside a greater sense of autonomy that is espoused and advocated. Again, these tensions operate at multiple levels, and between multiple partners – from national to regional, from regional to local, and back again.

Ownership | Partnership

Our data points to the ongoing challenge about where ownership for RIF sits, and the extent to which its programme of work truly involves a partnership approach, or something different. This speaks to the relationships of trust that (in stakeholder views and to a greater or lesser extent) exist across the Fund, again within and between regions, and between the regions and national government.

Structure | Agency

More generally, this final dyad recognises the nature of government time-limited funding like RIF and that it inherently sits within a certain paradigm. It recognises the challenge and tension within RIF of using ‘agency’ to undertake dynamic forms of transformation, within the context of pre-existing organisational structures. This is compounded when the transformation is actively trying to change the nature of the structures that is operating within.

Areas for further consideration

Following this analysis, we enumerate the following 11 cross-stakeholder ‘areas for further consideration’. These are not formal recommendations, but we recognise that our work to date has identified a number of issues which could usefully be considered, grouped under a series of sub-headings as below.

Working together

• How can we more effectively learn from each other within RIF, but also from others doing very similar work elsewhere, about common challenges and ways to overcome these?
• How could the principles, instructions and requirements of RIF be more aligned with the population assessments of the regions?
• How can the key stakeholders work together to co-design and agree a series of priorities for the coming years of RIF?
• What can be learnt from what is working well with the Communities of Practice and where they may be re-purposed and re-energised in alignment with the key intentions of RIF?
• How can we ensure that tensions as illustrated in the conceptual dyads do not inhibit progress or act as barriers in achieving the aims of RIF?

Data collection, reporting and resourcing

• What is the scope to rethink how a more proportionate balance can be struck between the need to collect high-quality data, and an efficient use of staff resources across all stakeholders (both national and regional) within RIF?
• How could the need to evidence and report compliance-based activities and outputs (‘data to prove’) shift to a more strategic and insights driven dataset (‘data to improve’) in line with the spirit of knowledge development for better integrated health and social care?
• How might the moves towards an all-Wales dataset help to drive consistency without creating excessive reporting requirements, including new insights on being able to identify and shape learning opportunities one from another?
• What are the implications of the current system, service and resource pressures – especially around financial sustainability – for the original goals of RIF?

Models of Care

• How could we shift towards greater clarity and definition, and better understanding around the Models of Care?
• How might re-thinking the ideas around the purpose of the Models of Care be used positively to connect areas of interesting and innovative practice without duplicating effort?

Report authors: Fiona Verity and Mark Llewellyn

Views expressed in this report are those of the researchers and not necessarily those of the Welsh Government.

For further information please contact:
Social Services and Integration Division
Welsh Government
Cathays Park
Cardiff
CF10 3NQ
Email: research.healthandsocialservices@gov.wales

Social research number: 1/2025
Digital ISBN: 978-1-83625-999-2